Updated: Helping Patients Who Drink Too Much

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Helping
Patients Who
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ACLINICIANSGUIDE
Updated 2005 Edition
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U.S. DEPARTMENT OF HEALTH & HUMAN SERVICES

National Institutes of Health
National Institute on Alcohol Abuse and Alcoholism
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Table of Contents
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
Whats the Same, Whats New in This Update. . . . . . . . . . . . . . . . . . . . 2
Before You Begin . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
How to Help Patients Who Drink Too Much: A Clinical Approach
Step 1: Ask About Alcohol Use . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
Step 2: Assess for Alcohol Use Disorders . . . . . . . . . . . . . . . . . . . . . . 5
Step 3: Advise and Assist
At-Risk Drinking . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
Alcohol Use Disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
Step 4: At Followup: Continue Support
At-Risk Drinking . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
Alcohol Use Disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
Appendix
Clinician Support Materials . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
Patient Education Materials . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24
Online Materials for Clinicians and Patients . . . . . . . . . . . . . . . . . . . . 27
Frequently Asked Questions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28
Notes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33
. . . men who drink more than 4 standard
drinks in a day (or more than 14 per week)
and women who drink more than 3 in a day
(or more than 7 per week) are at increased risk
for alcohol-related problems.
INTRODUCTION
Introduction
This Guide is written for primary care and mental health clinicians. It has
been produced by the National Institute on Alcohol Abuse and Alcoholism (NIAAA),
a component of the National Institutes of Health, with guidance from physicians,
nurses, advanced practice nurses, physician assistants, and clinical researchers.
How much is too much?
Drinking becomes too much when it causes or elevates the risk for alcohol-related
problems or complicates the management of other health problems. According to
epidemiologic research, men who drink more than 4 standard drinks in a day (or
more than 14 per week) and women who drink more than 3 in a day (or more
than 7 per week) are at increased risk for alcohol-related problems.
1
Individual responses to alcohol vary, however. Drinking at lower levels may be
problematic depending on many factors, such as age, coexisting conditions, and use
of medication. Because it isnt known whether any amount of alcohol is safe during
pregnancy, the Surgeon General urges abstinence for women who are or may
become pregnant.
2
Why screen for heavy drinking?
At-risk drinking and alcohol problems are common. About 3 in 10 U.S. adults
drink at levels that elevate their risk for physical, mental health, and social
problems.
3
Of these heavy drinkers, about 1 in 4 currently has alcohol abuse
or dependence.
3
All heavy drinkers have a greater risk of hypertension, gastro-
intestinal bleeding, sleep disorders, major depression, hemorrhagic stroke, cirrhosis
of the liver, and several cancers.
4
Heavy drinking often goes undetected. In a recent study of primary care
practices, for example, patients with alcohol dependence received the
recommended quality of care, including assessment and referral to treatment,
only about 10 percent of the time.
5
Patients are likely to be more receptive, open, and ready to change than
you expect. Most patients dont object to being screened for alcohol use by
clinicians and are open to hearing advice afterward.
6
In addition, most primary
care patients who screen positive for heavy drinking or alcohol use disorders show
some motivational readiness to change, with those who have the most severe
symptoms being the most ready.
7
Youre in a prime position to make a difference. Clinical trials have
demonstrated that brief interventions can promote significant, lasting reductions
in drinking levels in at-risk drinkers who arent alcohol dependent.
8
Some drinkers
who are dependent will accept referral to addiction treatment programs. Even for
patients who dont accept a referral, repeated alcohol-focused visits with a health
care provider can lead to significant improvement.
9,10
If youre not already doing so, we encourage you to incorporate alcohol screening
and intervention into your practice. With this Guide, you have what you need
to begin.
1
WHATS THE SAME, WHATS NEW
Whats the Same, Whats New in This Update
Same approach to screening and intervention
The approach to alcohol screening and intervention presented in the original 2005 Guide
remains unchanged. That edition established a number of new directions compared with
earlier versions, including a simplified, single-question screening question; more guidance for
managing alcohol-dependent patients; and an expanded target audience that includes mental
health practitioners, since their patients are more likely to have alcohol problems than
patients in the general population.
11,12
In the how-to section, two small revisions are noteworthy. Feedback from Guide users told
us that some patients do not consider beer to be an alcoholic beverage, so the prescreening
question on page 4 now reads, Do you sometimes drink beer, wine, or other alcoholic bever-
ages? And on page 5, the assessment criteria remain the same, but the sequence now better
reflects a likely progression of symptoms in alcohol use disorders.
Updated and new supporting materials
Updated medications section. The section on prescribing medications (pages 1316)
contains added information about treatment strategies and options. It describes a newly
approved, extended-release injectable drug to treat alcohol dependence that joins three
previously approved oral medications.
Medication management support. Patients taking medications for alcohol dependence
require some behavioral support, but this doesnt need to be specialized alcohol
counseling. For clinicians in general medicine and mental health settings, the Guide now
outlines a brief, effective program of behavioral support that was developed for patients
who received pharmacotherapy in a recent clinical trial (pages 1722).
Specialized alcohol counseling resource. For mental health clinicians who wish to
provide specialized counseling for alcohol dependence, weve added information about a
state-of-the-art behavioral intervention also developed for a recent clinical trial (page 31).
Online resources. A new page on the NIAAA Web site is devoted to the Guide and
related resources (www.niaaa.nih.gov/guide). See page 27 for a sampling of available forms,
publications, and training resources.
New patient education handout. Strategies for Cutting Down provides concise
guidance for patients who are ready to cut back or quit. The handout may be photo-
copied from page 26 or downloaded from www.niaaa.nih.gov/guide, where it is also
available in Spanish.
Transferred sections. Two appendix resources from the preceding edition (the sample
questions for assessment and the preformatted progress notes for baseline and followup
visits) are now available online at www.niaaa.nih.gov/guide. The previous Materials from
NIAAA section is now part of the Online Materials for Clinicians and Patients on
page 27.
2
Before You Begin
Decide on a screening method
The Guide provides two methods for screening: a single question (about heavy
drinking days) to use during a clinical interview and a written self-report
instrument (the AUDITsee page 11). The single interview question can be
used at any time, either in conjunction with the AUDIT or alone. Some
practices may prefer to have patients fill out the AUDIT before they see the
clinician. It takes less than 5 minutes to complete and can be copied or
incorporated into a health history.
Think about clinical indications for screening
Key opportunities include
As part of a routine examination
Before prescribing a medication that interacts with alcohol (see box on
page 29)
In the emergency department or urgent care center
When seeing patients who
are pregnant or trying to conceive
are likely to drink heavily, such as smokers, adolescents, and
young adults
have health problems that might be alcohol induced, such as
cardiac arrhythmia dyspepsia liver disease
depression or anxiety insomnia trauma
have a chronic illness that isnt responding to treatment as
expected, such as
chronic pain diabetes gastrointestinal disorders
depression heart disease hypertension
Set up your practice to simplify the process
Decide who will conduct the screening (you, other clinical personnel,
the receptionist who hands out the AUDIT)
Use preformatted progress notes (see Online Materials on page 27)
Use computer reminders (if using electronic medical records)
Keep copies of the pocket guide (provided) and referral information in your
examination rooms
Monitor your performance through practice audits
BEFORE YOU BEGIN . . .
3
HOW TO HELP PATIENTS: A CLINICAL APPROACH
How to Help Patients Who Drink Too Much: A Clinical Approach
STEP 1 Ask About Alcohol Use
Prescreen: Do you sometimes drink beer, wine, or other alcoholic beverages?
NO
Screening complete.
YES
Is the screening positive?
1 or more heavy drinking days or
AUDIT score of 8 for men or
4 for women
Ask the screening question about
heavy drinking days:
How many times in the past year
have you had . . .
5 or more drinks in 4 or more drinks in
a day? (for men) a day? (for women)
One standard drink is equivalent to 12 ounces of beer, 5 ounces
of wine, or 1.5 ounces of 80-proof spiritssee chart on page 24.
If the patient used a written self-
report (such as the AUDIT, p. 11),
START HERE
NO
Advise staying within these limits:
Maximum Drinking Limits
For healthy men up to age 65
no more than 4 drinks in a day AND
no more than 14 drinks in a week
For healthy women (and healthy men over
age 65)
no more than 3 drinks in a day AND
Recommend lower limits or abstinence as
medically indicated: for example, for patients
who
take medications that interact with alcohol
have a health condition exacerbated by
alcohol
are pregnant (advise abstinence)
Express openness to talking about alcohol use
and any concerns it may raise
Rescreen annually
YES
GO TO
STEP 2
Your patient is an at-risk drinker. For a more
complete picture of the drinking pattern,
determine the weekly average:
On average, how many days a
week do you have an alcoholic
drink?
X
On a typical drinking day, how
many drinks do you have?
Weekly average
Record heavy drinking days in the past year and
the weekly average in the patients chart (see page
27 for a downloadable baseline progress note).
4
STEP 2 Assess for Alcohol Use Disorders
Next, determine whether there is a maladaptive pattern of alcohol use, causing clinically significant
impairment or distress. It is important to assess the severity and extent of all alcohol-related symptoms
to inform your decisions about management. The following list of symptoms is adapted from the
Diagnostic and Statistical Manual of Mental Disorders, 4th Edition (DSM-IV), Revised. Sample assessment
questions are available online at www.niaaa.nih.gov/guide.
Determine whether, in the past 12 months, your patients drinking has repeatedly caused or
contributed to
risk of bodily harm (drinking and driving, operating machinery, swimming)
relationship trouble (family or friends)
role failure (interference with home, work, or school obligations)
run-ins with the law (arrests or other legal problems)
If yes to one or more your patient has alcohol abuse.
In either case, proceed to assess for dependence symptoms.
Determine whether, in the past 12 months, your patient has
not been able to stick to drinking limits (repeatedly gone over them)
not been able to cut down or stop (repeated failed attempts)
shown tolerance (needed to drink a lot more to get the same effect)
shown signs of withdrawal (tremors, sweating, nausea, or insomnia when trying to quit or
cut down)
kept drinking despite problems (recurrent physical or psychological problems)
spent a lot of time drinking (or anticipating or recovering from drinking)
spent less time on other matters (activities that had been important or pleasurable)
If yes to three or more your patient has alcohol dependence.
Does the patient meet the criteria for alcohol abuse or dependence?
NO
Your patient is still
at risk for developing
alcohol-related problems
GO TO
STEPS 3 & 4
for AT-RISK
DRINKING,
page 6
YES
Your patient has an
alcohol use disorder
GO TO
STEPS 3 & 4
for ALCOHOL USE
DISORDERS,
page 7
5
AT-RISK DRINKING (no abuse or dependence)
STEP 3 Advise and Assist (BriefIntervention)
Is the patient ready to commit to change at this time?
State your conclusion and recommendation clearly:
Youre drinking more than is medically safe. Relate to the patients concerns and medical findings, if present.
(Consider using the chart on page 25 to show increased risk.)
I strongly recommend that you cut down (or quit) and Im willling to help. (See page 29 for advice considerations.)
Gauge readiness to change drinking habits:
Are you willing to consider making changes in your drinking?
NO
Dont be discouragedambivalence is common. Your
advice has likely prompted a change in your patients
thinking, a positive change in itself. With continued
reinforcement, your patient may decide to take action.
For now,
Restate your concern about his or her health.
Encourage reflection by asking patients to weigh
what they like about drinking versus their reasons
for cutting down. What are the major barriers to
change?
Reaffirm your willingness to help when he
or she is ready.
YES
Help set a goal to cut down to within maximum
limits (see Step 1) or abstain for a time.
Agree on a plan, including
what specific steps the patient will take
(e.g., not go to a bar after work, measure
all drinks at home, alternate alcoholic and
nonalcoholic beverages).
how drinking will be tracked (diary, kitchen
calendar).
how the patient will manage high-risk situations.
who might be willing to help, such as
significant others or nondrinking friends.
Provide educational materials. See page 26 for
Strategies for Cutting Down and page 27 for
other materials available from NIAAA.
STEP 4 At Followup: Continue Support
REMINDER: Document alcohol use and review goals at each visit (see page 27 for downloadable progress notes).
Was the patient able to meet and sustain the drinking goal?
NO
Acknowledge that change is difficult.
Support any positive change and address
barriers to reaching the goal.
Renegotiate the goal and plan; consider a trial
of abstinence.
Consider engaging significant others.
Reassess the diagnosis if the patient is unable
to either cut down or abstain. (Go to Step 2.)
YES
Reinforce and support continued adherence
to recommendations.
Renegotiate drinking goals as indicated (e.g., if
the medical condition changes or if an abstaining
patient wishes to resume drinking).
Encourage the patient to return if unable to
maintain adherence.
Rescreen at least annually.
6
ALCOHOL USE DISORDERS (abuse or dependence)
STEP 3 Advise and Assist (BriefIntervention)
State your conclusion and recommendation clearly:
I believe that you have an alcohol use disorder. I strongly recommend that you quit drinking and Im willing to help.
Relate to the patients concerns and medical findings if present.
Negotiate a drinking goal:
Abstaining is the safest course for most patients with alcohol use disorders.
Patients who have milder forms of abuse or dependence and are unwilling to abstain may be successful at cutting down.
(See Step 3 for At-Risk Drinking.)
Consider referring for additional evaluation by an addiction specialist, especially if the patient is
dependent. (See page 23 for tips on finding treatment resources.)
Consider recommending a mutual help group.
For patients who have dependence, consider
the need for medically managed withdrawal (detoxification) and treat accordingly (see page 31).
prescribing a medication for alcohol dependence for those who endorse abstinence as a goal (see page 13).
Arrange followup appointments, including medication management support if needed (see page 17).
STEP 4 At Followup: Continue Support
REMINDER: Document alcohol use and review goals at each visit (see page 27 for downloadable progress notes).
If the patient is receiving a medication for alcohol dependence, medication management support should be provided
(see page 17).
Was the patient able to meet and sustain the drinking goal?
NO
Acknowledge that change is difficult.
Support efforts to cut down or abstain, while
making it clear that your recommendation is
to abstain.
Relate drinking to problems (medical,
psychological, and social) as appropriate.
If the following measures arent already being
taken, consider
referring to an addiction specialist or
consulting with one.
recommending a mutual help group.
engaging significant others.
prescribing a medication for alcohol-
dependent patients who endorse
abstinence as a goal.
Address coexisting disordersmedical and
psychiatricas needed.
YES
Reinforce and support continued adherence
to recommendations.
Coordinate care with a specialist if the patient
has accepted referral.
Maintain medications for alcohol dependence
for at least 3 months and as clinically indicated
thereafter.
Treat coexisting nicotine dependence for 6 to
12 months after reaching the drinking goal.
Address coexisting disordersmedical and
psychiatricas needed.
7
Appendix
Clinician Support Materials
Screening Instrument: The Alcohol Use Disorders Identification
Test (AUDIT) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
Supporting Patients Who Take Medications for
Medication Management Support for Alcohol Dependence
Prescribing Medications for Alcohol Dependence . . . . . . . . . . . . . . . . . 13
Alcohol Dependence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
Initial Session Template . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
Followup Session Template . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
Referral Resources . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23
Patient Education Materials
Whats a Standard Drink? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24
U.S. Adult Drinking Patterns . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25
Strategies for Cutting Down . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26
Online Materials for Clinicians and Patients . . . . . . . . . . . . . . . . . . . . 27
Frequently Asked Questions
About Alcohol Screening and Brief Interventions . . . . . . . . . . . . . . . . . 28
About Drinking Levels and Advice . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29
About Diagnosing and Helping Patients With
Alcohol Use Disorders. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31
Notes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33
CLINICIAN SUPPORT MATERIALS
Screening Instrument: The Alcohol Use Disorders
Identification Test (AUDIT)
Your practice may choose to have patients fill out a written screening
instrument before they see a clinician. In this Guide, the AUDIT is provided in
both English and Spanish for this purpose. It takes only about 5 minutes to
complete, has been tested internationally in primary care settings, and has high
levels of validity and reliability.
13
You may photocopy these pages or download
them from www.niaaa.nih.gov/guide.
Scoring the AUDIT
Record the score for each response in the blank box at the end of each line,
then total these numbers. The maximum possible total is 40.
Total scores of 8 or more for men up to age 60 or 4 or more for women,
adolescents, and men over 60 are considered positive screens.
14,15,16
For patients
with totals near the cut-points, clinicians may wish to examine individual
responses to questions and clarify them during the clinical examination.
Note: The AUDITs sensitivity and specificity for detecting heavy drinking
and alcohol use disorders varies across different populations. Lowering the
cut-points increases sensitivity (the proportion of true positive cases) while
increasing the number of false positives. Thus, it may be easier to use a
cut-point of 4 for all patients, recognizing that more false positives may be
identified among men.
Continuing with screening and assessment
After the AUDIT is completed, continue with Step 1, page 4.
10
PATIENT: Because alcohol use can affect your health and can interfere with certain medications and treatments, it
is important that we ask some questions about your use of alcohol. Your answers will remain confidential, so please
be honest.
Place an X in one box that best describes your answer to each question.
Questions 0 1 2 3 4
1. How often do you have a drink Never Monthly 2 to 4 2 to 3 4 or more
containing alcohol? or less times a month times a week times a week
2. How many drinks containing 1 or 2 3 or 4 5 or 6 7 to 9 10 or more
alcohol do you have on a typical
day when you are drinking?
3. How often do you have 5 or more Never Less than Monthly Weekly Daily or
drinks on one occasion? monthly almost daily
4. How often during the last year Never Less than Monthly Weekly Daily or
have you found that you were not monthly almost daily
able to stop drinking once you
had started?
have you failed to do what was monthly almost daily
normally expected of you because
of drinking?
have you needed a first drink in monthly almost daily
the morning to get yourself going
after a heavy drinking session?
have you had a feeling of guilt or monthly almost daily
remorse after drinking?
have you been unable to remem- monthly almost daily
ber what happened the night
before because of your drinking?
9. Have you or someone else been No Yes, but not in Yes, during
injured because of your drinking? the last year the last year
10. Has a relative, friend, doctor, or No Yes, but not in Yes, during
other health care worker been the last year the last year
concerned about your drinking or
suggested you cut down?
Total
Note: This questionnaire (the AUDIT) is reprinted with permission from the World Health Organization. To reflect standard drink sizes in the
United States, the number of drinks in question 3 was changed from 6 to 5. A free AUDIT manual with guidelines for use in primary care
settings is available online at www.who.org.
11
PACIENTE: Debido a que el uso del alcohol puede afectar su salud e interferir con ciertos medicamentos y
tratamientos, es importante que le hagamos algunas preguntas sobre su uso del alcohol. Sus respuestas sern
confidenciales, as que sea honesto por favor.
Marque una X en el cuadro que mejor describa su respuesta a cada pregunta.
Preguntas 0 1 2 3 4
1. Con qu frecuencia consume Nunca Una o De 2 a 4 De 2 a 3 4 o ms
alguna bebida alcohlica? menos veces al mes ms veces veces a
veces al mes a la semana la semana
2. Cuantas consumiciones de bebidas 1 o 2 3 o 4 5 o 6 De 7 a 9 10 o ms
alcohlicas suele realizar en un da
de consumo normal?
3. Con qu frecuencia toma 5 o ms Nunca Menos de Mensualmente Semanalmente A diario o
bebidas alcohlicas en un solo da? una vez casi a diario
al mes
4. Con qu frecuencia en el curso del
ltimo ao ha sido incapaz de parar
de beber una vez haba empezado?
Nunca Menos de
una vez
al mes
Mensualmente Semanalmente A diario o
casi a diario
5. Con qu frecuencia en el curso del Nunca Menos de Mensualmente Semanalmente A diario o
ltimo ao no pudo hacer lo que se una vez casi a diario
esperaba de usted porque haba al mes
bebido?
ltimo ao ha necesitado beber en una vez casi a diario
ayunas para recuperarse despus de al mes
haber bebido mucho el da anterior?
ltimo ao ha tenido remor- una vez casi a diario
dimientos o sentimientos de culpa al mes
despus de haber bebido?
ltimo ao no ha podido recordar una vez casi a diario
lo que sucedi la noche anterior al mes
porque haba estado bebiendo?
9. Usted o alguna otra persona ha No S, pero no S, el ltimo
resultado herido porque usted haba en el curso del ao
bebido? ltimo ao
10. Algn familiar, amigo, mdico o No S, pero no S, el ltimo
profesional sanitario ha mostrado en el curso del ao
preocupacin por un consumo de ltimo ao
bebidas alcohlicas o le ha sugerido
que deje de beber?
Total
Note: This questionnaire (the AUDIT) is reprinted with permission from the World Health Organization and the Generalitat Valenciana
Conselleria De Benestar Social. To reflect standard drink sizes in the United States, the number of drinks in question 3 was changed from 6 to 5.
A free AUDIT manual with guidelines for use in primary care is available online at www.who.org.
12
Prescribing Medications for Alcohol Dependence
Three oral medications (naltrexone, acamprosate, and disulfiram) and one
injectable medication (extended-release injectable naltrexone) are currently
approved for treating alcohol dependence. They have been shown to help
patients reduce drinking, avoid relapse to heavy drinking, achieve and maintain
abstinence, or gain a combination of these effects. As is true in treating any
chronic illness, addressing patient adherence systematically will maximize the
effectiveness of these medications (see Supporting Patients Who Take
Medications for Alcohol Dependence, page 17).
When should medications be considered for treating an alcohol use
disorder?
All approved drugs have been shown to be effective adjuncts to the treatment of
alcohol dependence. Thus, consider adding medication whenever youre treat-
ing someone with active alcohol dependence or someone who has stopped
drinking in the past few months but is experiencing problems such as craving
or slips. Patients who have previously failed to respond to psychosocial
approaches alone are particularly strong candidates.
Must patients agree to abstain?
No matter which alcohol dependence medication is used, patients who have a
goal of abstinence, or who can abstain even for a few days prior to starting the
medication, are likely to have better outcomes. Still, its best to determine indi-
vidual goals with each patient. Some patients may not be willing to endorse
abstinence as a goal, especially at first. If a patient with alcohol dependence
agrees to reduce drinking substantially, its best to engage him or her in that
goal while continuing to note that abstinence remains the optimal outcome.
A patients willingness to abstain has important implications for the choice of
medication. Most studies on effectiveness have required patients to abstain
before starting treatment. A study of oral naltrexone, however, demonstrated a
modest reduction in the risk of heavy drinking in people with mild dependence
who chose to cut down rather than abstain.
17
A study of injectable naltrexone
suggests that it, too, may reduce heavy drinking in dependent patients who are
not yet abstinent, although it had a more robust effect in those who abstained
for 7 days before starting treatment
18
and is only approved for use in those who
can abstain in an outpatient setting before treatment begins. Acamprosate, too,
is only approved for use in patients who are abstinent at the start of treatment.
And disulfiram is contraindicated in patients who wish to continue to drink,
because a disulfiram-alcohol reaction occurs with any alcohol intake at all.
Which of the medications should be prescribed?
Which medication to use will depend on clinical judgment and patient prefer-
ence. Each has a different mechanism of action. Some patients may respond
better to one type of medication than another.
13
Naltrexone
Mechanism: Naltrexone blocks opioid receptors that are involved in the rewarding
effects of drinking alcohol and the craving for alcohol. Its available in two forms: oral
(Depade, ReVia), with once daily dosing, and extended-release injectable
(Vivitrol), given as once monthly injections.
Efficacy: Oral naltrexone reduces relapse to heavy drinking, defined as 4 or more drinks
per day for women and 5 or more for men.
19,20
It cuts the relapse risk during the first
3 months by about 36 percent (about 28 percent of patients taking naltrexone relapse
versus about 43 percent of those taking a placebo).
20
Thus, it is especially helpful for
curbing consumption in patients who have drinking slips. It is less effective in
maintenance of abstinence.
19,20
In the single study available when this Guide update was
published, extended-release injectable naltrexone resulted in a 25 percent reduction in
the proportion of heavy drinking days compared with a placebo, with a higher rate of
response in males and those with lead-in abstinence.
18
Acamprosate
Mechanism: Acamprosate (Campral) acts on the GABA and glutamate
neurotransmitter systems and is thought to reduce symptoms of protracted abstinence
such as insomnia, anxiety, restlessness, and dysphoria. Its available in oral form (three
times daily dosing).
Efficacy: Acamprosate increases the proportion of dependent drinkers who maintain
abstinence for several weeks to months, a result demonstrated in multiple European
studies and confirmed by a meta-analysis of 17 clinical trials.
21
The meta-analysis
reported that 36 percent of patients taking acamprosate were continuously abstinent
at 6 months, compared with 23 percent of those taking a placebo.
More recently, two large U.S. trials failed to confirm the efficacy of acamprosate,
22,23
although secondary analyses in one of the studies suggested possible efficacy in patients
who had a baseline goal of abstinence.
23
A reason for the discrepancy between European
and U.S. findings may be that patients in European trials had more severe dependence
than patients in U.S. trials,
21,22
a factor consistent with preclinical studies showing that
acamprosate has a greater effect in animals with a prolonged history of dependence.
24
In addition, before starting medication, most patients in European trials had been
abstinent longer than patients in U.S. trials.
25
Disulfiram
Mechanism: Disulfiram (Antabuse) interferes with degradation of alcohol, resulting
in accumulation of acetaldehyde which, in turn, produces a very unpleasant reaction
including flushing, nausea, and palpitations if the patient drinks alcohol. Its available
in oral form (once daily dosing).
Efficacy: The utility and effectiveness of disulfiram are considered limited because
compliance is generally poor when patients are given it to take at their own discretion.
26
It is most effective when given in a monitored fashion, such as in a clinic or by a
spouse.
27
(If a spouse or other family member is the monitor, instruct both monitor and
patient that the monitor should simply observe the patient taking the medication and
call you if the patient stops taking the medication for 2 days.) Some patients will
respond to self-administered disulfiram, however, especially if theyre highly motivated
to abstain. Others may use it episodically for high-risk situations, such as social
occasions where alcohol is present.
14
How long should medications be maintained?
The risk for relapse to alcohol dependence is very high in the first 6 to
12 months after initiating abstinence and gradually diminishes over several
years. Therefore, a minimum initial period of 3 months of pharmacotherapy is
recommended. Although an optimal treatment duration hasnt been established,
it isnt unreasonable to continue treatment for a year or longer if the patient
responds to medication during this time when the risk of relapse is highest.
After patients discontinue medications, they may need to be followed more
closely and have pharmacotherapy reinstated if relapse occurs.
If one medication doesnt work, should another be prescribed?
If theres no response to the first medication selected, you may wish to consider
a second. This sequential approach appears to be common clinical practice,
but currently there are no published studies examining its effectiveness.
Similarly, there is not yet enough evidence to recommend a specific ordering
of medications.
Is there any benefit to combining medications?
A large U.S. trial found no benefit to combining acamprosate and naltrexone.
22
More broadly, there is no evidence that combining any of the medications to
treat alcohol dependence improves outcomes over using any one medication
alone.
Should patients receiving medications also receive specialized alcohol
counseling or a referral to mutual help groups?
Offering the full range of effective treatments will maximize patient choice and
outcomes, since no single approach is universally successful or appealing to
patients. The different approachesmedications for alcohol dependence,
professional counseling, and mutual help groupsare complementary. They
share the same goals while addressing different aspects of alcohol dependence:
neurobiological, psychological, and social. The medications arent prone to
abuse, so they dont pose a conflict with other support strategies that emphasize
abstinence.
Almost all studies of medications for alcohol dependence have included some
type of counseling, and its recommended that all patients taking these medica-
tions receive at least brief medical counseling. In a recent large trial, the combi-
nation of oral naltrexone and brief medical counseling sessions delivered by a
nurse or physician was effective without additional behavioral treatment by a
specialist.
22
Patients were also encouraged to attend support groups to increase
social encouragement for abstinence. For more information, see Supporting
Patients Who Take Medications for Alcohol Dependence on page 17 and
Should I recommend any particular behavioral therapy for patients with
alcohol use disorders? on page 31.
15
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The information in this chart was drawn primarily from package inserts and references 18, 20, 22, and 26 (see pages 3334).
January 2007
16
Supporting Patients Who Take Medications for
Alcohol Dependence
Pharmacotherapy for alcohol dependence is most effective when combined
with some behavioral support, but this doesnt need to be specialized, intensive
alcohol counseling. Nurses and physicians in general medical and mental health
settings, as well as counselors, can offer brief but effective behavioral support
that promotes recovery. Applying this medication management approach in
such settings would greatly expand access to effective treatment, given that
many patients with alcohol dependence either dont have access to specialty
treatment or refuse a referral.
How can general medical and mental health clinicians support patients
who take medication for alcohol dependence?
Managing the care of patients who take medication for alcohol dependence is
similar to other disease management strategies such as initiating insulin therapy
in patients with diabetes mellitus. In the recent Combining Medications and
Behavioral Interventions (COMBINE) clinical trial, physicians, nurses, and
other health care professionals in outpatient settings delivered a series of brief
behavioral support sessions for patients taking medications for alcohol depend-
ence.
22
The sessions promoted recovery by increasing adherence to medication
and supporting abstinence through education and referral to support groups.
22
This Guide offers a set of how-to templates outlining this program (see pages
1922). It was designed for easy implementation in nonspecialty settings, in
keeping with the national trend toward integrating the treatment of substance
use disorders into medical practice.
What are the components of medication management support?
Medication management support consists of brief, structured outpatient
sessions conducted by a health care professional. The initial session starts by
reviewing the medical evaluation results with the patient as well as the negative
consequences from drinking. This information frames a discussion about the
diagnosis of alcohol dependence, the recommendation for abstinence, and the
rationale for medication. The clinician then provides information on the
medication itself and adherence strategies, and encourages participation in a
mutual support group such as Alcoholics Anonymous (AA).
In subsequent visits, the clinician assesses the patients drinking, overall
functioning, medication adherence, and any side effects from the medication.
Session structure varies according to the patients drinking status and treatment
compliance, as outlined on page 22. When a patient doesnt adhere to the
medication regimen, its important to evaluate the reasons and help the patient
devise plans to address them. A helpful summary of strategies for handling
nonadherence is provided in the Medical Management Treatment Manual
from Project COMBINE, available online at www.niaaa.nih.gov/guide.
17
As conducted in the COMBINE trial, the program consisted of an initial
session of about 45 minutes followed by eight 20-minute sessions during
weeks 1, 2, 4, 6, 8, 10, 12, and 16. General medical or mental health practices
may not follow this particular schedule, but its offered along with the
templates as a starting point for developing a program that works for your
practice and your patients.
Can medication management support be used with patients who dont
endorse a goal of abstinence?
This medication management program has been tested only in patients for
whom abstinence was recommended, as is true with most pharmacotherapy
studies. Its not known whether it would also work if the patients goal is to cut
back instead of abstain. Even when patients do endorse abstinence as a
goal, they often cut back without quitting. Youre encouraged to continue
working with those patients who are working toward recovery but havent yet
met the optimal goals of abstinence or reduced drinking with full remission
of dependence symptoms. You may also find many of the techniques used in
medication management supportsuch as linking symptoms and laboratory
results with heavy alcohol useto be helpful for managing alcohol-dependent
patients in general.
18
Initial Session Template
page 1 of 2
This template outlines the first in a series of appointments designed to support patients diagnosed with alcohol
dependence who are starting a course of medication to help them maintain abstinence.
Date: Time spent:
Patient name:
Pertinent history:
Observations:
Before counseling:
Record from the patients chart:
Alcohol-dependence medication prescribed:
naltrexone PO XR-naltrexone injectable acamprosate disulfiram other:
dose and schedule:
Lab results and other patient information (fill in the left column of the chart below, to the degree possible)
Gather:
Patient information on the medication (available, for example, from www.medlineplus.gov)
Wallet emergency card for naltrexone or disulfiram (see www.niaaa.nih.gov/guide)
Listing of local mutual help groups. For AA, see www.aa.org; for other groups, see the National
Clearinghouse for Alcohol and Drug Information Web site at www.ncadi.samhsa.gov under Resources.
Patient information
from the chart or patient report,
this forms the basis for counseling
Counseling
delivered in a nonjudgmental way, this enhances patient
motivation and provides the rationale for medication
1
Review lab results and medical adverse
consequences of heavy drinking:
Liver function test results:
AST (SGOT):
ALT (SGPT):
GGT (GGTP):
Total Bilirubin:
Albumin:
Blood pressure: / Pulse:
Other medical conditions affected by drinking
and relevant lab results:
diabetes heart disease GI:
insomnia depression anxiety pain
other:
other relevant lab results (e.g., MCV):
Tie results and symptoms to heavy alcohol use:
Describe normal liver function and adverse effects of
heavy drinking, then discuss results of liver function
tests:
If normal range: This is a positive sign that your liver has avoided
harm so far, and that now you have the opportunity to keep it
that way by changing your drinking habits. Having a healthy liver
will also help you make a quicker, more complete recovery.
If abnormal: The test results are most likely a sign of unhealthy
changes in your liver from heavy alcohol use. The longer you
continue to drink, the harder it is to reverse the damage. But if
you stop drinking, you may be able to get your liver function
back to normal.
If blood pressure is elevated, describe relationship
between high blood pressure and heavy drinking.
Describe relationship between condition(s) and heavy
drinking, including relevant lab results.
19
Initialpage 2 of 2
Review amount of drinking and nonmedical
adverse consequences of heavy drinking:
Amount of drinking: When was last drink?
In the past 30 days,
how many drinking days (any alcohol): days
how many heavy drinking days (5+ drinks/day for men,
4+ drinks/day for women): days
Nonmedical adverse consequences:
interpersonal employment/school legal
specify:
2
Focus more on the consequences of drinking than
on the quantity:
I see that when you drink, you drink heavily, and that youve
reported some problems related to that, such as (x). We see these
as (additional) signs that drinking is harmful for you.
Confirm diagnosis of alcohol dependence.
3
Recommend abstinence and provide rationale for
medications:
You have a diagnosis of alcohol dependence. (Provide patient
materials if available.) We strongly recommend that you stop
drinking altogether. For someone with alcohol dependence, this
is the safest choice. Its also best for your health. Quitting is
hard, which is why a medication has been prescribed that may
help you abstain.
Review the patients decision on abstinence:
Is the patient willing to abstain? yes no
Comment:
4
If the patient is unwilling or unable to commit to
abstinence, offer a trial period:
If youre thinking that lifelong abstinence is too difficult a goal to
commit to right now, you could try a brief period of, say, a month
to find out what its like to live without alcohol. Would you be
willing to try this out?
If a trial of abstinence isnt accepted, reconsider whether
medication is still appropriate with a modified goal.
Provide medication counseling, focusing on
5
6
7
Mechanism of action and time course of effects. Describe how Adherence strategies. Discuss the patients history of pill-taking
the medication works and how long it may take to be effective. practices, then strategies to promote adherence, such as taking pills
Potential side effects. Discuss the likelihood of side effects
at the same time each day, using weekly pill containers, and
(see the package insert) and ways to cope with adverse events
enlisting others support.
such as nausea or diarrhea. Advise the patient to contact you if Emergency cards. For naltrexone, educate the patient about
concerned about side effects. potential complications with opioid use and analgesics. For disulfi-
Dosing and adherence. Review the dosing regimen, remind the
ram, educate the patient about the alcohol-disulfiram reaction and
patient to take the medication consistently for effectiveness, and
avoiding alcohol in food and medicines. Give the patient wallet
explain what to do if a dose is skipped.
emergency cards: (initials and date)
Encourage participation in a mutual support group:
Provide list of local options and describe the benefits of
If the patient has attended a meeting before and wasnt
attendance. Note that attending AA or another mutual support
comfortable: Not all groups are alike. Its likely that youll
group is a way to acquire a network of friends who have found
need to try several before finding one that feels right.
ways to live without alcohol. Tell the patient that medication is If the patient is concerned about members disapproving of his
time limited and that the importance of mutual support groups or her medication: The medication is a tool youll use in an
increases when medications are stopped. effort not to drink. It has been shown to help others stop
Address barriers to attendance:
drinking. Also, its not addicting. And the official policy of AA
If the patient is reluctant to attend: Would you be willing to
supports people taking nonaddicting medicines prescribed by
try just one meeting before our next session?
a doctor.
Wrap up:
Summarize the diagnosis and Ask about remaining questions Other followup:
recommendation for abstinence or concerns
Summarize dosage regimen Schedule the next visit
20
8
Next appointment date:

Followup Session Template
page 1 of 2
Date: Time spent:
Patient name:
Vital signs (if taken): BP: / P: Weight:
Laboratory data (if available): GGT: AST: ALT: Other:
General progress and patient concerns since the last visit:
Observations of patient cognition: Mood:
Physical signs: Other:
Drinking status
How long since the last drink? days/weeks/months
In the past 30 days (or since the last visit if less than 30 days):
how many drinking days (any alcohol): days in the past days
how many heavy drinking days (5+ drinks/day for men, 4+ drinks/day for women):
days in the past days
Other:
Alcohol pharmacotherapy
Medications prescribed: none naltrexone PO XR-naltrexone injectable acamprosate
disulfiram other:
In the past 30 days (or since the last visit if less than 30 days), how many days has the patient taken
medication? days in the past days
Side effects: none nausea vomiting diarrhea headache injection site reaction
other:
Patients perception of the medications effectiveness: helpful not helpful not sure
specify:
Other treatment received
Since your last visit, have you:
Yes No
Started any new medications? (specify)
Attended mutual support groups? If yes, how often?
Received alcohol or addiction counseling? (specify)
Received other counseling? (specify)
Entered a treatment program?
residential intensive outpatient other (specify)
Been hospitalized for alcohol or drug use? (specify)
Been treated for withdrawal (shakes)? (specify)
21
Counseling provided (check the dialogue used)
Is the patient drinking?
NO
Is the patient adherent
to medications?
NO
Congratulate the
patient for not
drinking
Review the benefits
of pharmacotherapy
Ask why the
medications are not
taken regularly
Explore possible
remedies to correct
nonadherence
Set the next
appointment
YES
Reinforce the
patients ability to
follow advice and
stick to the plan
Ask what the patient
has done to achieve
this outcome
Encourage the
patient to stick with
the planKeep up
the good work!
Review the benefits
of abstinence
Set the next
appointment
YES
Is the patient adherent
to medications?
NO
Review the initial
reasons for seeking
treatment (i.e.,
negative consequences
of drinking)
Review the benefits
of abstinence and
pharmacotherapy
Review the reasons
for medication
nonadherence
Create a new adherence
plan, addressing
barriers to treatment
and providing sugges-
tions on minimizing
drinking cues
Encourage the patient
to give treatment a
chance
Set the next
appointment
YES
Praise any small steps
toward abstinence
(e.g., fewer heavy
drinking days)
Review the benefits
of abstinence
Review the benefits
of mutual support
group meetings
Remind the patient
that medications take
time to work
Set the next
appointment
Followuppage 2 of 2
Other recommendations (e.g., side effects management, new adherence plan):
Followup: Continue the current treatment plan
Change the treatment plan as follows:
(for nurses): Refer to physician for medical evaluation
Next appointment date:
22
Referral Resources
When making referrals, involve your patient in the decisions and schedule a
referral appointment while he or she is in your office.
Finding evaluation and treatment options
For patients with insurance, contact a behavioral health case manager at the
insurance company for a referral.
For patients who are uninsured or underinsured, contact your local health
department about addiction services.
For patients who are employed, ask whether they have access to an
Employee Assistance Program with addiction counseling.
To locate treatment options in your area:
Call local hospitals to see which ones offer addiction services.
Call the National Drug and Alcohol Treatment Referral Routing Service
(1-800-662-HELP) or visit the Substance Abuse Facility Treatment
Locator Web site at http://findtreatment.samhsa.gov.
Finding support groups
Alcoholics Anonymous (AA) offers free, widely available groups of
volunteers in recovery from alcohol dependence. Volunteers are often
willing to work with professionals who refer patients. For contact
information for your region, visit www.aa.org.
Other mutual help organizations that offer secular approaches, groups for
women only, or support for family members can be found on the National
Clearinghouse for Alcohol and Drug Information Web site
(www.ncadi.samhsa.gov) under Resources.
Local resources
Use the space below for contact information for resources in your area
(treatment centers, mutual support groups such as AA, local government servic-
es, the closest Veterans Affairs medical center, shelters, churches).
23
PATIENT EDUCATION MATERIALS
Whats a Standard Drink?
A standard drink in the United States is any drink that contains about 14 grams of pure alcohol (about
0.6 fluid ounces or 1.2 tablespoons). Below are U.S. standard drink equivalents. These are approximate,
since different brands and types of beverages vary in their actual alcohol content.
12 oz. of
beer or
cooler
5 oz. of
table wine
34 oz. of
fortified wine
(such as
sherry or port)
3.5 oz. shown
23 oz. of
cordial,
liqueur, or
aperitif
2.5 oz. shown
1.5 oz. of
brandy
(a single jigger)
1.5 oz. of
spirits
(a single jigger
of 80-proof
gin, vodka,
whiskey, etc.)
Shown straight and
in a highball glass
with ice to show
the level before
adding a mixer*
89 oz. of
malt liquor
8.5 oz. shown in
a 12-oz. glass that,
if full, would hold
about 1.5 standard
drinks of malt liquor
~5% alcohol ~7% alcohol ~12% alcohol ~17% alcohol ~24% alcohol ~40% alcohol ~40% alcohol

12 oz. 8.5 oz. 5 oz. 3.5 oz. 2.5 oz. 1.5 oz. 1.5 oz.
Many people dont know what counts as a standard drink and so they dont realize how many standard
drinks are in the containers in which these drinks are often sold. Some examples:
For beer, the approximate number of standard drinks in
12 oz. = 1 22 oz. = 2
16 oz. = 1.3 40 oz. = 3.3
For malt liquor, the approximate number of standard drinks in
12 oz. = 1.5 22 oz. = 2.5
16 oz. = 2 40 oz. = 4.5
For table wine, the approximate number of standard drinks in
a standard 750-mL (25-oz.) bottle = 5
For 80-proof spirits, or hard liquor, the approximate number of standard drinks in
a mixed drink = 1 or more* a fifth (25 oz.) = 17
a pint (16 oz.) = 11 1.75 L (59 oz.) = 39
*Note: It can be difficult to estimate the number of standard drinks in a single mixed drink made with hard
liquor. Depending on factors such as the type of spirits and the recipe, a mixed drink can contain from one to
three or more standard drinks.
24
U.S. Adult Drinking Patterns
Nearly 3 in 10 U.S. adults engage in at-risk drinking patterns
3
and thus would benefit from advice to cut down
or a referral for further evaluation. During a brief intervention, you can use this chart to show that (1) most people
abstain or drink within the recommended limits and (2) the prevalence of alcohol use disorders rises with heavier
drinking. Though a wise first step, cutting to within the limits is not risk free, since motor vehicle crashes and other
problems can occur at lower drinking levels.
WHATS
YOUR
DRINKING
PATTERN?
HOW
COMMON
IS THIS
PATTERN?
HOW COMMON ARE
ALCOHOL DISORDERS
IN DRINKERS WITH
THIS PATTERN?
Based on the following limitsnumber of drinks:
On any DAYNever more than 4 (men) or 3 (women)
and
In a typical WEEKNo more than 14 (men) or 7 (women)
Percentage of
U.S. adults
aged 18
or older*
Combined
prevalence
of alcohol abuse
and dependence**
Never exceed the daily or weekly limits
(2 out of 3 people in this group abstain or
drink fewer than 12 drinks a year)
72%
fewer than
1 in 100
Exceed only the daily limit
(More than 8 out of 10 in this group exceed
the daily limit less than once a week)
16%
1 in 5
Exceed both daily and weekly limits
(8 out of 10 in this group exceed
the daily limit once a week or more)
10%
almost
1 in 2
* Not included in the chart, for simplicity, are the 2 percent of U.S. adults who exceed only the weekly limits. The combined prevalence of alcohol use
disorders in this group is 8 percent.
** See page 5 for the diagnostic criteria for alcohol disorders.
25
Strategies for Cutting Down
Small changes can make a big difference in reducing your chances of having alcohol-related problems. Here are some
strategies to try. Check off some to try the first week, and add some others the next.
Keeping track
Keep track of how much you drink. Find a way that works for you, such as a 3x5" card in your wallet, check marks on
a kitchen calendar, or a personal digital assistant. If you make note of each drink before you drink it, this will help you
slow down when needed.
Counting and measuring
Know the standard drink sizes so you can count your drinks accurately. One standard drink is 12 ounces of regular
beer, 8 to 9 ounces of malt liquor, 5 ounces of table wine, or 1.5 ounces of 80-proof spirits. Measure drinks at home.
Away from home, it can be hard to know the number of standard drinks in mixed drinks. To keep track, you may
need to ask the server or bartender about the recipe.
Setting goals
Decide how many days a week you want to drink and how many drinks
youll have on those days. You can reduce your risk of alcohol dependence
and related problems by drinking within the limits in the box to the right.
Its a good idea to have some days when you dont drink.
Pacing and spacing
When you do drink, pace yourself. Sip slowly. Have no more than one
drink with alcohol per hour. Alternate drink spacersnonalcoholic
drinks such as water, soda, or juicewith drinks containing alcohol.
Including food
Dont drink on an empty stomach. Have some food so the alcohol will
be absorbed more slowly into your system.
Avoiding triggers
What triggers your urge to drink? If certain people or places make you
drink even when you dont want to, try to avoid them. If certain activities,
times of day, or feelings trigger the urge, plan what youll do instead of
drinking. If drinking at home is a problem, keep little or no alcohol there.
MAXIMUM DRINKING LIMITS
FOR HEALTHY ADULTS*
For healthy men up to age 65
no more than 4 drinks in a day
AND
For healthy women (and healthy
men over age 65)
no more than 3 drinks in a day
AND
* Dependingonyourhealthstatus,yourdoctor
mayadviseyoutodrinklessorabstain.
Planning to handle urges
When an urge hits, consider these options: Remind yourself of your reasons for changing. Or talk it through with
someone you trust. Or get involved with a healthy, distracting activity. Or urge surf instead of fighting the feeling,
accept it and ride it out, knowing that it will soon crest like a wave and pass.
Knowing your no
Youre likely to be offered a drink at times when you dont want one. Have a polite, convincing no, thanks ready.
The faster you can say no to these offers, the less likely you are to give in. If you hesitate, it allows you time to think
of excuses to go along.
Additional tips for quitting
If you want to quit drinking altogether, the last three strategies can help. In addition, you may wish to ask for support
from people who might be willing to help, such as a significant other or nondrinking friends. Joining Alcoholics
Anonymous or another mutual support group is a way to acquire a network of friends who have found ways to live with-
out alcohol. If youre dependent on alcohol and decide to stop drinking completely, dont go it alone. Sudden withdrawal
from heavy drinking can cause dangerous side effects such as seizures. See a doctor to plan a safe recovery.
26
ONLINE MATERIALS FOR CLINICIANS AND PATIENTS
Online Materials for Clinicians and Patients
Visit the NIAAA Web site at www.niaaa.nih.gov/guide for these and other materials to support you in alcohol
screening, brief interventions, and followup patient care. NIAAA continually develops and updates materials
for practitioners and patients; please check the Web site for new offerings. You may also order materials by
writing to the NIAAA Publications Distribution Center, P.O. Box 10686, Rockville, MD 20849-0686 or
calling 3014433860.
Clinician support and training
Forms for downloading
Screening instrument: The Alcohol Use Disorders Identification Test
(AUDIT) in English and Spanish
Assessment support: Sample questions for assessment of alcohol use disorders
Preformatted progress notes and templates
o Baseline and followup progress notes
o Medication management support templates
Medication wallet card form
Animated slide show
This 80-slide PowerPoint show helps instructors present the content of the
Guide to students and professionals in the general medicine and mental health
fields.
Online training
Coming in spring 2007: Online training in screening and brief intervention
for Continuing Medical Education credit.
Publications for professionals
Alcohol Alerts: These 4-page bulletins provide timely information on alcohol
research and treatment.
Alcohol Research & Health: Each issue of this quarterly peer-reviewed journal
contains review articles on a central topic related to alcohol research.
A Pocket Guide for Alcohol Screening and Brief Intervention: This is a
condensed, portable version of this publication.
Spanish edition of the Guide: Ayudando a Pacientes Que Beben en Exceso
Guia Para Profesionales de la Salud.
Patient education
Handouts for downloading
In English and Spanish: Strategies for Cutting Down; U.S. Adult Drinking
Patterns; Whats a Standard Drink?
Publications for the public
In English and Spanish: Alcohol: A Womens Health Issue; Frequently Asked
Questions about Alcoholism and Alcohol Abuse; A Family History of Alcoholism:
Are You at Risk? and more
27
FREQUENTLY ASKED QUESTIONS
Frequently Asked Questions
About alcohol screening and brief
interventions
How effective is screening for heavy drinking?
Studies have demonstrated that screening is
sensitive and that patients are willing to give honest
information about their drinking to health care
practitioners when appropriate methods are used.
6,15
Several methods have been shown to work,
including quantity-frequency interview questions
and questionnaires such as the CAGE, the AUDIT,
the shorter AUDIT-C, the TWEAK (for pregnant
women), and others.
28,29
In this Guide, the single
screening question about heavy drinking days was
chosen for its simplicity and because almost all
people with alcohol use disorders report drinking
5 or more drinks in a day (for men) or 4 or more
(for women) at least occasionally. This Guide also
recommends the AUDIT (provided on page 11)
as a self-administered screening tool because of
its high levels of validity and reliability.
15
With the single interview question, screening is
positive with just one heavy drinking day in the
past year. Isnt that casting a very broad net?
A common reaction to the screening question
is, Everybodys going to meet this, at least
occasionally. A large national survey by NIAAA,
however, showed that nearly three-fourths of U.S.
adults never exceed the limits in the screening
question.
3
Even if patients report that they only
drink heavily on rare occasions, screening provides
an opportunity to educate them about safe
drinking limits so that heavy drinking doesnt
become more frequent. The risk for alcohol-related
problems rises with the number of heavy drinking
days,
1
and some problems, such as driving while
intoxicated or trauma, can occur with a single
occasion.
How effective are brief interventions?
Randomized, controlled clinical trials in a variety
of populations and settings have shown that brief
interventions can decrease alcohol use significantly
among people who drink above the recommended
limits but arent dependent. In several intervention
trials with multiple brief contacts, for example,
heavy drinkers cut an average of three to nine
drinks per week, for a 13 to 34 percent net
reduction in consumption.
30
Even relatively modest
reductions in drinking can have important health
benefits when spread across a large number of
people. Brief intervention trials have also reported
significant decreases in blood pressure readings,
levels of gamma-glutamyl transferase (GGT),
psychosocial problems, hospital days, and hospital
readmissions for alcohol-related trauma.
8
Followup
periods typically range from 6 to 24 months,
although one recent study reported sustained
reductions in alcohol use over 48 months.
8
A cost-
benefit analysis in this study showed that each
dollar invested in brief physician intervention could
reap more than fourfold savings in future health
care costs. Other research shows that for alcohol-
dependent patients with an alcohol-related medical
illness, repeated brief interventions at approximate-
ly monthly intervals for 1 to 2 years can lead to
significant reductions in or cessation of drinking.
9,10
What can I do to encourage my patients to give
honest and accurate answers to the screening
questions?
Its often best to ask about alcohol consumption
at the same time as other health behaviors such
as smoking, diet, and exercise. Using an empathic,
nonconfrontational approach can help put patients
at ease. Some clinicians have found that prefacing
the alcohol questions with a nonthreatening opener
such as Do you enjoy a drink now and then? can
encourage reserved patients to talk. Patients may
feel that a written or computerized self-report
version of the AUDIT is less confrontational as
well. To improve the accuracy of estimated
drinking quantities, you could ask patients to look
at the Whats a Standard Drink? chart on page
24. Many people are surprised to learn what counts
as a single standard drink, especially for beverages
with a higher alcohol content such as malt liquors,
fortified wines, and spirits. The chart also lists the
number of standard drinks in commonly purchased
beverage containers. In some situations, you may
consider adding the questions How often do you
buy alcohol? and How much do you buy? to
help build an accurate estimate.
28
How can a clinic- or office-based screening
system be implemented?
The best studied method, which is both easy and
efficient, is to ask patients to fill out the 10-item
AUDIT before seeing the doctor. This form
(provided on page 11) can be added to others that
patients fill out. The full AUDIT or the 3-item
AUDIT-C can also be incorporated into a larger
health history form. The AUDIT-C consists of
the first three consumption-related items of the
AUDIT; a score of 6 or more for men and 4 or
more for women
31
indicates a positive screen.
Alternatively, the single-item screen in Step 1 of
this Guide could be incorporated into a health
history form. Screening can also be done in person
by a nurse during patient check-in. (See also
Set Up Your Practice to Simplify the Process
on page 3.)
Are there any specific considerations for imple-
menting screening in mental health settings?
Studies have demonstrated a strong relationship
between alcohol use disorders and other mental
disorders.
32
Heavy drinking can cause psychiatric
symptoms such as depression, anxiety, insomnia,
cognitive dysfunction, and interpersonal conflict.
For patients who have an independent psychiatric
disorder, heavy drinking may compromise the
treatment response. Thus, it is important that all
mental health clinicians conduct routine screening
for heavy drinking.
Less is known about the performance of screening
methods or brief interventions in mental health
settings than in primary care settings. Still, the
single-question screener in this Guide is likely to
work reasonably well, since almost everyone with
an alcohol use disorder reports drinking above the
recommended daily limits at least occasionally.
Mental health clinicians may need to conduct a
more thorough assessment to determine whether an
alcohol use disorder is present and how it might be
interacting with other mental or substance use
disorders. The recommended limits for drinking
may need to be lowered depending on coexisting
problems and prescribed medications.
Similarly, a more extended behavioral intervention
may be needed to address coexisting alcohol use
disorders, either delivered as part of mental health
treatment or through referral to an addiction
specialist.
About drinking levels and advice
When should I recommend abstaining versus
cutting down?
Certain conditions warrant advice to abstain as
opposed to cutting down. These include when
drinkers:
are or may become pregnant
are taking a contraindicated medication
(see box below)
have a medical or psychiatric disorder caused by
or exacerbated by drinking
have an alcohol use disorder
If patients with alcohol use disorders are unwilling
to commit to abstinence, they may be willing to
cut down on their drinking. This should be
encouraged while noting that abstinence, the safest
strategy, has a greater chance of long-term success.
For heavy drinkers who dont have an alcohol use
disorder, use professional judgment to determine
whether cutting down or abstaining is more
appropriate, based on factors such as these:
Interactions Between Alcohol and Medications
Alcohol can interact negatively with medications either by interfering with the metabolism of the
medication (generally in the liver) or by enhancing the effects of the medication (particularly in the
central nervous system). Many classes of prescription medicines can interact with alcohol, including
antibiotics, antidepressants, antihistamines, barbiturates, benzodiazepines, histamine H2 receptor agonists,
muscle relaxants, nonopioid pain medications and anti-inflammatory agents, opioids, and warfarin. In
addition, many over-the-counter medications and herbal preparations can cause negative side effects when
taken with alcohol.
29
a family history of alcohol problems
advanced age
injuries related to drinking
symptoms such as sleep disorders or sexual
dysfunction
It may be useful to discuss different options,
such as cutting down to recommended limits or
abstaining completely for perhaps a month or two,
then reconsidering future drinking. If cutting down
is the initial strategy but the patient is unable to
stay within limits, recommend abstinence.
How do I factor the potential benefits of
moderate drinking into my advice to patients
who drink rarely or not at all?
Moderate consumption of alcohol (defined by U.S.
Dietary Guidelines as up to two drinks a day for
men and one for women) has been associated with
a reduced risk of coronary heart disease.
33
Achieving
a balance between the risks and benefits of alcohol
consumption remains difficult, however, because
each person has a different susceptibility to diseases
potentially caused or prevented by alcohol. The
advice you would give to a young person with a
family history of alcoholism, for example, would
differ from the advice you would give to a middle-
aged patient with a family history of premature
heart disease. Most experts dont recommend
advising nondrinking patients to begin drinking
to reduce their cardiovascular risk. However, if a
patient is considering this, discuss safe drinking
limits and ways to avoid alcohol-induced harm.
Why are the recommended drinking limits lower
for some patients?
The limits are lower for women because they have
proportionally less body water than men do and
thus achieve higher blood alcohol concentrations
after drinking the same amount of alcohol. Older
adults also have less lean body mass and greater
sensitivity to alcohols effects. In addition, there are
many clinical situations where abstinence or lower
limits are indicated, because of a greater risk of
harm associated with drinking. Examples include
women who are or may become pregnant, patients
taking medications that may interact with alcohol,
young people with a family history of alcohol
dependence, and patients with physical or
psychiatric conditions that are caused by or
exacerbated by alcohol.
Some of my patients who drink heavily believe
that this is normal. What percentage of people
drink at, above, or below moderate levels?
About 7 in 10 adults abstain, drink rarely, or drink
within the daily and weekly limits noted in Step 1.
3
The rest exceed the daily limits, the weekly limits,
or both. The U.S. Adult Drinking Patterns chart
on page 25 shows the percentage of drinkers in
each category, as well as the prevalence of alcohol
use disorders in each group. Because heavy drinkers
often believe that most people drink as much and
as often as they do, providing normative data about
U.S. drinking patterns and related risks can provide
a helpful reality check. In particular, those who
believe that its fine to drink moderately during
the week and heavily on the weekends need to
know that they have a higher chance not only of
immediate alcohol-related injuries, but also of
developing alcohol use disorders and other alcohol-
related medical and psychiatric disorders.
Some of my patients who are pregnant dont see
any harm in having an occasional drink. Whats
the latest advice?
Some pregnant women may not be aware of the
risks involved with drinking, while others may
drink before they realize theyre pregnant. A recent
survey estimates that 1 in 10 pregnant women in
the United States drinks alcohol.
34
In addition,
among sexually active women who arent using
birth control, more than half drink and 12.4
percent report binge drinking, placing them at
particularly high risk for an alcohol-exposed
pregnancy.
34
Each year, an estimated 2,000 to 8,000 infants are
born with fetal alcohol syndrome in the United
States, and many thousands more are born with
some degree of alcohol-related effects.
35
These
problems range from mild learning and behavioral
problems to growth deficiencies to severe mental
and physical impairment. Together, these adverse
effects comprise fetal alcohol spectrum disorders.
Because it isnt known whether any amount of
alcohol is safe during pregnancy, the Surgeon
General recently reissued an advisory that urges
women who are or may become pregnant to
abstain from drinking alcohol.
2
The advisory also
recommends that pregnant women who have
already consumed alcohol stop to minimize further
30
risks and that health care professionals inquire
routinely about alcohol consumption by women of
childbearing age.
About diagnosing and helping
patients with alcohol use disorders
What if a patient reports some symptoms of an
alcohol use disorder but not enough to qualify
for a diagnosis?
Alcohol use disorders are similar to other medical
disorders such as hypertension, diabetes, or
depression in having gray zones of diagnosis. For
example, a patient might report a single arrest for
driving while intoxicated and no other symptoms.
Since a diagnosis of alcohol abuse requires
repetitive problems, that diagnosis couldnt be
made. Similarly, a patient might report one or two
symptoms of alcohol dependence, but three are
needed to qualify for a diagnosis.
Any symptom of abuse or dependence is a cause for
concern and should be addressed, since an alcohol
use disorder may be present or developing. These
patients may be more successful with abstaining as
opposed to cutting down to recommended limits.
Closer followup is indicated, as well as
reconsidering the diagnosis as more information
becomes available.
Should I recommend any particular behavioral
therapy for patients with alcohol use disorders?
Several types of behavioral therapy are used to
treat alcohol use disorders. Cognitive-behavioral
therapy, motivational enhancement, and 12-step
facilitation (e.g., the Minnesota Model) have all
been shown to be effective.
36
A combination of
approaches has been shown to be effective as well
(see the next question). Getting help in itself
appears to be more important than the particular
approach used, provided it avoids heavy con-
frontation and incorporates the basic elements of
empathy, motivational support, and an explicit
focus on changing drinking behavior. For patients
receiving medications for alcohol dependence, brief
medical counseling sessions delivered by a nurse or
physician have been shown to be effective without
additional behavioral treatment by a specialist
22
(see page 17).
In addition to more formal treatment approaches,
mutual help groups such as Alcoholics Anonymous
(AA) appear to be very beneficial for people who
stick with them. AA is widely available, free, and
requires no commitment other than a desire to
stop drinking. If youve never attended a meeting,
consider doing so as an observer and supporter.
To learn more, visit www.aa.org. Other self-help
organizations that offer secular approaches, groups
for women only, or support for family members
can be found on the National Clearinghouse for
Alcohol and Drug Information Web site
(www.ncadi.samhsa.gov) under Resources.
As a mental health clinician, how can I learn
more about specialized alcohol counseling?
For a recent major clinical trial, NIAAA grantees
designed state-of-the-art individual outpatient
psychotherapy for alcohol dependence. Called
a combined behavioral intervention (CBI),
it integrates cognitive-behavioral therapy,
motivational enhancement, 12-step approaches,
couples therapy, and community reinforcement
all treatments shown in earlier studies to be
beneficial. Behavioral specialists deliver CBI in up
to 20 sessions of 50 minutes (the median in the
trial was 10 sessions). The treatment has four
phases: building motivation for change, developing
an individual plan for treatment and change,
completing individualized skill-training modules,
and performing maintenance checkups. Findings
from the trial show that this specialized alcohol
counseling or the medication naltrexone was
effective, when coupled with structured medical
management.
22
The CBI strategy and supporting
materials are provided in the 328-page Combined
Behavioral Intervention Manual from Project
COMBINE; to order for a small fee, visit
www.niaaa.nih.gov/guide.
How should alcohol withdrawal be managed?
Alcohol withdrawal results when a person who
is alcohol dependent suddenly stops drinking.
Symptoms usually start within a few hours and
consist of tremors, sweating, elevated pulse and
blood pressure, nausea, insomnia, and anxiety.
Generalized seizures may also occur. A second
syndrome, alcohol withdrawal delirium, sometimes
follows. Beginning after 1 to 3 days and lasting
31
2 to 10 days, it consists of an altered sensorium,
disorientation, poor short-term memory, altered
sleep-wake cycle, and hallucinations. Management
typically consists of administering thiamine and
benzodiazepines, sometimes together with
anticonvulsants, beta adrenergic blockers, or
antipsychotics as indicated. Mild withdrawal can
be managed successfully in the outpatient setting,
but more complicated or severe cases require
hospitalization. (Consult references 37 and 38 on
page 34 for additional information.)
Are laboratory tests available to screen for
or monitor alcohol problems?
For screening purposes in primary care settings,
interviews and questionnaires have greater
sensitivity and specificity than blood tests for
biochemical markers, which identify only about
10 to 30 percent of heavy drinkers.
39,40
Nevertheless,
biochemical markers may be useful when heavy
drinking is suspected but the patient denies it. The
most sensitive and widely available test for this
purpose is the serum gamma-glutamyl transferase
(GGT) assay. It isnt very specific, however, so
reasons for GGT elevation other than excessive
alcohol use need to be eliminated. If elevated at
baseline, GGT and other transaminases may also
be helpful in monitoring progress and identifying
relapse, and serial values can provide valuable
feedback to patients after an intervention. Other
blood tests include the mean corpuscular volume
(MCV) of red blood cells, which is often elevated
in people with alcohol dependence, and the
carbohydrate-deficient transferrin (CDT) assay.
The CDT assay is about as sensitive as the GGT
and has the advantage of not being affected by
liver disease.
41
If I refer a patient for alcohol treatment, what
are the chances for recovery?
A review of seven large studies of alcoholism
treatment found that about one-third of patients
either were abstinent or drank moderately without
negative consequences or dependence in the year
following treatment.
42
Although the other two-
thirds had some periods of heavy drinking, on
average they reduced consumption and alcohol-
related problems by more than half. These
reductions appear to last at least 3 years.
36
This
substantial improvement in patients who do not
attain complete abstinence or problem-free reduced
drinking is often overlooked. These patients may
require further treatment, and their chances of
benefiting the next time dont appear to be
influenced significantly by having had prior
treatments.
42
As is true for other medical disorders,
some patients have more severe forms of alcohol
dependence that may require long-term
management.
What can I do to help patients who struggle to
remain abstinent or who relapse?
Changing drinking behavior is a challenge,
especially for those who are alcohol dependent.
The first 12 months of abstinence are especially
difficult, and relapse is most common during this
time. If patients do relapse, recognize that they
have a chronic disorder that requires continuing
care, just like asthma, hypertension, or diabetes.
Recurrence of symptoms is common and similar
across each of these disorders,
43
perhaps because
they require the patient to change health behaviors
to maintain gains. The most important principle is
to stay engaged with the patient and to maintain
optimism about eventual improvement. Most
people with alcohol dependence who continue to
work at recovery eventually achieve partial to full
remission of symptoms, and often do so without
specialized behavioral treatment.
44
For patients who
struggle to abstain or who relapse:
If the patient is not taking medication for
alcohol dependence, consider prescribing one
and following up with medication management
(see pages 1322).
Treat depression or anxiety disorders if they are
present more than 2 to 4 weeks after abstinence
is established.
Assess and address other possible triggers for
struggle or relapse, including stressful events,
interpersonal conflict, insomnia, chronic pain,
craving, or high-temptation situations such as a
wedding or convention.
If the patient is not attending a mutual help
group or is not receiving behavioral therapy,
consider recommending these support measures.
Encourage those who have relapsed by noting
that relapse is common and pointing out the
value of the recovery that was achieved.
Provide followup care and advise patients to
contact you if they are concerned about relapse.
32
NOTES
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34
NIH Publication No. 073769
Reprinted May 2007

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